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Avoiding the avoidable: The Ombudsman’s second annual public lecture

Parliamentary and Health Service Ombudsman

Last year, the former Chief Medical Officer, Sir Liam Donaldson, agreed to act as independent adviser to a review of how the Parliamentary and Health Service Ombudsman draws on clinical advice in its casework. The review was chaired by non-executive Board member, Sir Alex Allan.

As we prepare our response to the review for publication this spring, I am delighted to share this Radio Ombudsman podcast of our second annual Ombudsman lecture, at which Sir Liam was the main speaker. 

Like Radio Ombudsman, our annual lecture is a space to stimulate public dialogue about our role and learn from others how we can work with them to improve public services. 

Improving the safety of NHS care

The majority of complaints we receive are about the NHS, so I was interested to hear Sir Liam’s lecture exploring how the NHS and system leaders can ‘avoid the avoidable’ to improve the safety of NHS care. 

Sir Liam, currently patient safety adviser at the World Health Organisation, encouraged us to think about patient safety failures as a sequence of events rather than a single incident that can be attributed to one individual. 

He stressed that blaming individuals for errors inhibits learning. Open cultures that proactively encourage reporting and reflection are critical for improving patient safety.  

Our role in driving improvements 

As an independent ombudsman service, we handle thousands of complaints about the NHS in England every year. As I explained at the lecture, this gives us a unique evidence base about the quality and safety of care. 

During 2017-18 we received 24,664 NHS complaints. We looked in detail at 5,545 of these and we completed 2,355 investigations. Our casework provides redress for individuals. It also provides learning for the individual organisations we investigate and whole pathways or systems of care. 

One example is our 2017 Insight report on eating disorders. This has led to a change in national (NICE) guidance on eating disorders care and prompted NHS England to take action to improve access to adult eating disorder services. 

This is just one of the ways we are driving improvements in the quality of care. As part of our 2018-21 strategy we are also committed to publishing the majority of our casework outcomes online, so others can use the learning to improve health services. 

We are also working in partnership with stakeholders to improve frontline complaint handling, so that patients have a better experience when they raise a concern or make a complaint. People should not always have to come to the Ombudsman to get an open and honest response when things go wrong. 

These are all important steps and it is right that our organisation continues to encourage improvement in the quality of public services, including the NHS. But it is clear from Sir Liam’s work, and the experiences of people who work in or use health services, that we all have a role to play in creating the culture of learning that is necessary to improve the safety of patient care. 

A diverse and engaged audience

I was pleased to see a diverse and engaged audience attend the event. We heard from Stephen Powis, National Medical Director of NHS England, Mick King, the Local Government and Social Care Ombudsman, patient safety leaders from NHS Trusts and representatives from the Healthcare Safety Investigative Branch. 

It was also valuable to hear from people who have used our service and are now patient safety campaigners. This included Scott Morrish, who has fought tirelessly to shift the culture of the NHS from blame to learning. 

This combination of perspectives, insightful questions and contributions presented us all with an opportunity to consider the role each of us plays in improving patient safety, and how we work together to achieve this. 

Listen now

I encourage you to listen to the podcast below:

Please share our podcasts widely and let us know what you think by leaving a review or comment on SoundCloud or iTunes, or tweet us @PHSOmbudsman